Ep. 3: Amy Boutwell, MD, MPP, President of Collaborative Healthcare Strategies. Topic: Readmissions
Kathy: Hi everyone, and thank you so much for joining us for Episode 3 of the Smarter Healthcare Podcast. I’ve received positive feedback on the first two episodes of the podcast series – I’m glad you’ve been enjoying the conversations I’ve been having with healthcare leaders and influencers.
On this episode, I’ll be talking to Dr. Amy Boutwell, President of Collaborative Healthcare Strategies, about the topic of readmissions, which is when patients come back to the hospital within 30 days of a previous stay. As hospitals and health systems focus on the Quadruple Aim – improving patient care, lowering costs, and improving both the patient and physician experience – reducing readmissions is one area that could have a significant positive impact.
Amy is a nationally recognized thought leader in the field of reducing readmissions and improving care for highest risk and multi-visit patients. She is the developer of the STAAR, ASPIRE, ASPIRE+ and MVP methods to reduce avoidable acute-care utilization and deliver whole-person care across settings and over time.
Without further ado, here is my conversation with Amy. I hope you enjoy it!
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Kathy: Hi Amy, thanks for joining me today.
Amy: Good to be here. Thanks for having me.
Kathy: Now Amy, a lot of your work focuses on readmissions. Where do hospitals stand right now with regards to that?
Amy: Well, Kathy, the great news is is that nationally, we’re making measurable progress on reducing readmissions. And so, when we look at the state level and the national level, we can look at some specific, measurable progress that’s been made in reducing readmissions overall and in certain states. So I’ll start first with the big picture. So nationally, Medicare really has been the leader since the passage of the Affordable Care Act in pushing hospitals to reduce readmissions, and overall nationally, we see that readmissions are down by about 6%. The really exciting news is that states are doing even better. And there’s only a few states at this point, but again in the past five-to-ten years or so, two states in particular have really stood out in terms of bringing down readmissions at a state-wide level, and those two states are Maryland and New York. In New York, the goal has been to reduce overall hospital use including readmissions, and readmissions, avoidable hospitalizations, and total cost in New York for the Medicaid population is down about 20%, which is incredible. Nobody would have thought that was possible. And then the other exciting state is Maryland, where statewide they’ve reduced readmissions by 14%, which is more than two times better than the national rate of reduction. So they’ve done great work in Maryland as well, again, beating the national readmission reduction trend by over – twofold. So when we look nationally, we see readmissions coming down and then we look at these pockets of excellence where policy and investments are really making a difference in transforming the healthcare system. Now with regard to individual hospitals, there’s variation literally across the board. There’s an entire bell curve of performance. And so some hospitals have not improved and in fact have sustained worsening readmissions rates. And then many hospitals in the middle are holding steady or slightly improving, and then on an individual hospital basis we always find high performers that have figured out how to do well and reduce readmissions in a variety of ways. So the field is varied, but with a lot of success to point to.
Kathy: Great, and we’ll talk about some of those best practices that some of those higher-performing hospitals have done in just a minute. Obviously, we want to reduce readmissions for the human factor, you don’t want sick patients coming back to the hospital, but what are some of the other reasons that hospitals really need to get a handle on readmissions?
Amy: So, really, I’m going to start with the policy and the design objective. About ten years ago I was afforded the opportunity to develop a strategy to reduce hospital use, taking the state – not the hospital – as the unit of interest. This was really distinctive because even ten years ago, research and healthcare economic analysis suggested that we were overusing hospitals. So this really comes from the overuse of hospital services angle – really the entire field of looking at readmissions. And so we ask, why would we be using hospitals so much differently in Massachusetts than in Washington state? Are the patients really sicker or poorer or are we – is the healthcare system really better? And the answer to that at a national analytic basis was no, no, and no. There’s just unwarranted variation and so really this came from the observation that there was high overuse of hospitalizations and that there was geographic unwarranted variation, meaning that it was not because healthcare was better somewhere or patients were sicker somewhere else. And so I was – before the passage of the Affordable Care Act while I was at the Institute for Healthcare Improvement, I was asked to lead the effort to design a strategy to reduce hospitalizations in a given state. And in the process of looking at how do we reduce hospital use, it became clear that the innermost circle of reducing avoidable hospital use is to take on the first order challenge, which is to make sure that the patients who were just in the hospital or currently in the hospital don’t need to come back. And that is the heart of readmission reduction. So when we look at reduced – a lot of people don’t know this that reducing readmissions came from the first order challenge of reducing unwarranted variation in overuse of hospitalizations, and that the innermost circle is to say the most measurable and thus potentially impactable way to reduce all hospitalizations is to look at the 20% of discharges that are coming back within 30 days. Let’s get that down and then grow out from there. And so again when we then dug in deeper and started to learn about readmissions and the root causes of readmissions and the data around readmissions there was again unwarranted variation in readmission rates across hospitals and for patients even with the same co-morbidities, or payer type, or conditions. And that really has stimulated this decade of working to reduce readmissions because readmissions are too high, they can be safely lowered, and they’re really the inner circle of being able to reduce avoidable hospital use. And that really gets us – connects the past, where readmission reduction policy and design came from to – where we’ll get by the end of the podcast which is looking towards the future, where does this work lead us in the future. So that’s the policy and the design, which is think of readmissions not just as a patient leaves and a patient comes back – and I’ll get to that in a moment – but it’s the innermost circle on what we now call high-value healthcare. Which is how do we deliver the right care in the right place at the right time and reduce unwarranted and unnecessary acute care utilization? So then there’s the clinical reason. And the clinical reason is hopefully evident to anyone who has done a readmission root-cause analysis. Not a readmission chart review and not just looking at data. But if you’ve ever spoken to a patient and their family who has been in the hospital and who’s needed to return you immediately start to see the human factor, the human face of readmissions, and the system breakdowns. So we have patients who entrust that we are giving them the information that they need to recover safely and successfully once we transition them from the hospital to the next setting of care, whether that’s a rehab, or home with home healthcare, or home with their own self-management. And unfortunately, we are not doing that. And it turns out that when we talk to patients and their caregivers about the circumstances that led them to come back, there’s frustration, there’s confusion, there’s a lack of linkages, there’s a lack of follow-through, there’s a lack of just really ensuring a good transition. And that leads us to the system factors, which are could any one doctor or nurse have done a better job? Really the answer is no, because we work in a system that is not yet designed to deliver care across settings and over time such that one of the big fallacies of readmissions is that a doctor or a nurse should just have ought to have done better, worked harder, been smarter, cared more, and this is not at all true. The limitation of why we experience higher or lower readmission rates is not the fault of individual actors in the system, but rather a property of the system itself. And so we really see readmissions not as a clinical quality indicator – how good was the clinical care at that hospital – but rather as a system property. Does this healthcare system have the infrastructure to successfully deliver care across settings and over time? And listeners may be interested that in Massachusetts, the state data - healthcare data analytics agency, we call it CHIA – the Center for Healthcare Information and Analysis – we actually file our readmission reports under ‘Health System Performance’ and we don’t file readmission reports under ‘Healthcare Quality’, making that very clear distinction that readmissions is a measure – one measure, but a measure of - the goodness of the healthcare system and not necessarily the goodness of the clinical healthcare quality that was delivered. So really interesting food for thought for those of you that haven’t thought about readmissions as a health system property before.
Kathy: Yeah, I really like that way of thinking about it. That it’s more of a system issue and like you said the performance and not necessarily the individual providers.
Amy: Correct.
Kathy: Now let’s talk about some best practices when it comes to reducing readmissions. So a hospital’s data can be very useful in helping to determine root causes. Can you talk about that a little bit?
Amy: Oh, absolutely. So what’s been a blessing – a mixed blessing, I’ll say, in terms of the first ten years of readmission reduction work, is that CMS – Medicare – has sent the very clear signals to hospitals that they ought to reduce readmissions for certain targeted conditions. We all know what they are – heart failure, COPD, AMI, pneumonia, et cetera. Now, the blessing is, in quality improvement, we all have to start somewhere, and we all have to learn about the quality measure and clinical factors that go into making progress, and so focus is always a good thing when we’re learning. The challenge is that the disease-specific readmission penalty program from Medicare has stymied the field in looking at their own data. And so we have taken it as a given that CMS tells us heart failure patients are high risk of readmission. Pneumonia patients are high risk of readmission. AMI patients are high risk of readmission. When in fact a hospital needs to look at its own data to ask the question, “Which of our patients are experiencing high numbers or high rates of readmissions?” Now the big a-ha has come from the publication of the guide that I wrote for the Agency for Healthcare Research and Quality. What we were asked to do by AHRQ was adapt the strategies and practices and thinking that were becoming the practices of the day for Medicare patients, and AHRQ very wisely asked my team, ‘In what ways do those practices and thinking and approaches need to be modified or adapted for the Medicaid population?’ And that led us straight into a hospital payer-non-specific all-cause disease non-specific readmission analysis. So if we want to reduce readmissions for Medicare and Medicaid or indeed all of our patients at a hospital, step one is to look at our own hospital’s data and say, what are the major leading causes or causes of readmissions from our hospital, not just what Medicare tells us? And so looking at that analysis can right off the bat, if your hospital hasn’t done that, and I’m sure many of you have at this point, but that was a real pivot about five years ago, to look at not just the data from Medicare but look at your own hospital’s all cause, all-payer readmission data. A couple of key a-ha moments that I’m very, very glad ended up really changing practice nationally was the number one or number two diagnosis associated with the most readmissions at a hospital in a state, and in the country is sepsis. Sepsis, as a physician, makes so much sense to me that it would show up as a top leading cause of readmissions. Why? Because the definition of sepsis is that you – a patient had a systemic whole-body infection that caused severe vasodilation and lowering of blood pressure and impact on the kidneys and the other vital organs - that they were trying to die. And we, hopefully we saved them, but holding all of their home medications, pumping them full of fluids, often three antibiotics, and we save them from sepsis. And get them to the point of being ready for discharge, but naturally this group of patients are at much, much higher risk of readmission than any of these so-called chronic illnesses that we had been told to focus on by Medicare. So this is just one way and I’ll give a second compelling example as well in a moment, but this is one way that allowing a third-party to tell us who our high-risk patient groups are is, I would say, not only incomplete data, but it’s actually not quite responsible, I’ll go so far as to say that. And remember the sepsis example, when provoked by that concept that it’s not even responsible, we have a responsibility in improving patient care, to know our own data with regard to whatever measure at hand, and to understand what’s going on with our own patients in our own four walls with regard to the measure of concern, in this case, readmissions. And so sepsis came to the front and I’m happy to say that in learning collaboratives and readmission reduction initiatives across the country over the past few years, we have really put sepsis and the effort to reduce sepsis readmissions, again, because it’s a compelling clinical need, we’ve elevated that onto the agenda of many, many hospitals across the country, because that’s what the data told us. So that’s a big win. Now, we struggle with another element of wrestling with our data that has not yet been a big win. And that is with respect to another breakthrough analysis that we recommended in the AHRQ Reducing Readmissions Guide. I call it the ASPIRE Guide. And the – listeners will notice on the analytic – the hospital all-cause readmission analysis that we recommend that we have an analysis there saying, what is the readmission rate among any patient who has a behavioral health co-morbidity? So we’re always looking at acute care hospitals – people who are here for cellulitis, and heart attacks, and pneumonia, and sepsis, and all of the quote - medical reasons - but one of the breakthrough insights is looking at the readmission rate not by primary diagnosis but by whether or not that person has a behavioral health condition – any behavioral health condition, such as depression, anxiety, yes, serious mental illness like bipolar or schizophrenia, and/or any substance use disorder. So very broad swath of just saying does this person with heart failure also have a behavioral health co-morbidity? And we did this analysis, we have done this analysis very rigorously in Massachusetts with the state data agency, CHIA, and what we have found is something that’s very important food for thought when being guided by data. We found that the readmission rate for anyone with a behavioral health co-morbidity who’s hospitalized in Massachusetts, is 77% higher than anyone who’s hospitalized in Massachusetts without a behavioral health co-morbidity. That’s basically the single most important risk-screen that anyone needs. And in the AHRQ guide to Reducing Medicaid Readmissions, if I had to say what was the biggest contribution of that guide to the readmission reduction field, it was the use of data to highlight how important it is to look for and treat behavioral health co-morbidity as a pervasive risk factor that identifies a very high-risk target population even above and beyond any of the quote - medical reasons - that someone is in the hospital. And I’m happy to say that teams that have embraced the data and deliver - screen for behavioral health co-morbidities and deliver transitional care accordingly, attending to the mind and behavioral health needs of the patient as well as the schematic and diagnosis, primary diagnosis-based needs of the patient, do very, very well with achieving their goals. And hospitals that would like to believe that behavioral health is not their concern because they’re not a psych hospital continue to struggle. So that is a big – those are two big takeaways on using your own data and letting the data tell you where to focus. Now, if I may, take just a moment on one of my most favorite topics, which is root causes – so you asked me about data and root causes so I will emphasize that when I first started leading initiatives to reduce readmissions, the major practice at the bedside with readmission reduction teams, or case management teams, was to do a chart review. And the chart review was basically answering – asking and answering the question, did we do everything we should have done and did we document the right plan of care. Right, so did we do teach-back? Did we do a med rec? Did we schedule an appointment? And if the answer was yes, yes, and yes, then literally I remember thousands of case managers across the country would say this readmission was unavoidable because we - the implied or explicit rationale was because we did everything right. And if we did everything right, according to our own scorecard, then it was out of our hands, whether or not the patient returned. Well a breakthrough in perspective was offered by the first guidebook that I wrote with my colleagues at the Institute for Healthcare Improvement, which was called the STAAR initiative, and we introduced to the field the readmission interview, saying, “Dear doctors and nurses and case managers across America, it is not your opinion as to whether or not you did an A+ job, it is the patient’s opinion.” And you can imagine that ten years ago this was quite radical. But in the decade since it’s become a very common practice. So again if you’re not doing readmission interviews and asking the patient and the caregiver what brings them back, and we need to listen for the questions, the frustrations, the bumps in the road that occurred out there in the messy real world of being sick and having questions and needing to pick up meds and being faced with prior authorizations and expensive medications or rides that never came or home health or BME that was never delivered, that is the focus of – of the readmission interview. We need to know what happened quote – out there – that brought people back to the hospital because those are the system issues that we need to address. We cannot just mollify ourselves by saying we did teach-back, we made an appointment, we did a post-discharge call, check, check, check, nothing more we can do. And again, that brings us very much beyond the four walls of the hospital and into what healthcare system and infrastructure are we discharging our patients into so that we can ensure a truly safe and successful transition into the community. So doing a readmission interview is, in my opinion, the only possible way to understand why readmissions occur, and again, in my dozen years of doing this all day every day I have literally never found a chart review to be helpful.
Kathy: It’s all about that being more patient-centric, understanding their experience.
Amy: Exactly.
Kathy: So what other best practices are rising to the top?
Amy: Yeah, so we’ll move from data and root causes into the bedside and out there into the community. So I’ll draw upon one of the major paradigms in the ASPIRE Guide, which is the paradigm that after we use our data and understand root causes to understand who’s at risk of readmission and why do our patients come back, then the third major paradigm of the ASPIRE Guide is to embrace, or understand that every hospital has a set of levers to pull upon in order to achieve their readmission reduction goals. And those levers are essentially to have a portfolio of strategies. We’ve all heard the trite saying “there’s no silver bullet,” and the ASPIRE Guide really helps listeners understand if there is no silver bullet then what is the playbook. And so the playbook is to have a portfolio of strategies which includes a minimum of three elements. And those three elements are, we need to number one, improve standard care across the board for all patients regardless of readmission risk and diagnosis, in certain ways, so this would be raising the boat for all. This is raising and elevating the standard of care that we deliver in our hospitals per se. And so some examples would be, again, looking for behavioral health co-morbidities and identifying that as a concern that needs to be accounted for in a transitional care plan. Including the caregiver as a member of the team right from the beginning, not just at the point of discharge, handing them the discharge paperwork but including them as a member of the team to become that proxy transitional care person on behalf of the patient. And other practices like that. So what can we do for every patient every day to elevate the standard of care, and by the way, improving standard care for all, as my colleagues in New York have recognized, pays dividends for not only reducing readmissions, but achieving reductions in harm, like falls and medication errors, reducing length of stay, and increasing HCAHPS scores. So when we improve our care processes on the floors of the hospital on a day-to-day basis, it is a cross-cutting strategy to achieve numerous priorities that many hospitals have today. OK. Strategy number two is we have to actively collaborate with what I call receiving providers and agencies in the community. So this is called cross-continuing collaboration. This is not a handoff. It’s not even a warm handoff. It’s definitely not interoperable medical records. This is processes and practices, professional agency to professional agency, to ensure that we are working together and closing the loop and problem-solving over time. The classic example for many hospitals across the country would be cross-continuing collaboration with skilled nursing facilities. And, again, thankfully many, many hospitals across the country have built close collaborative relationships with post-acute providers, and what they do is they look at data every month, they talk about readmissions, they talk about root causes of readmissions, and they make the changes iteratively, month by month by month, to strengthen their shared processes to reduce those shared readmission events. So that is a very important element of the portfolio. I should hasten to say that the Medicaid readmission equivalent of this would be similar cross-continuing collaboration with, especially, behavioral health providers and community-based agencies, social service agencies specifically. So for Medicare the natural partner would be post-acute, and other elder services. For Medicaid it would be much more the behavioral and social services in the community. And then finally we get to what everybody wants to know about, which is the models, so I’ll call them the models. We all know the Coleman Model, the Naylor Model, et cetera. And this would be the third element of the portfolio I call enhanced services. Meaning, we’re going to hire and deploy additional staff to do additional work at the point of transition and usually for the 30 days beyond. And who should the – what should that model look like? Should we choose Model A over Model B? And the answer is, well, you’re going to need a couple models. So the Naylor Model is evidence-based and highly effective and just one that I very much appreciate – it’s - Naylor Model, I should clarify for listeners, is a nurse practitioner actively managing care from prior to discharge through 30 or 60 days post-discharge, asking the questions of the PCP, the specialists involved, aligning care plans, clarifying and streamlining regimens and requests of the patient and their caregivers according to mostly geriatric medicine principles. And attending to, again, mostly geriatric medicine issues like goals of care, activities of daily living, cognitive limitations. The usefulness of a geriatric nurse practitioner for that high-risk population is absolutely clear and evidence-based. So that would be a model to apply to your older adult population, multiple co-morbidities, nearing the end of life, et cetera. A great model for that. Well, wait a second, we’re a hospital that serves adults of all ages. So, exactly as we said in the data analytic element of the podcast, we would then naturally need to ask the question, well what do we do for those patients with behavioral health co-morbidities that Doctor Boutwell highlighted as so high a readmission? For behavioral, for patients with behavioral health co-morbidities and naturally social needs that we’re all focusing on, the social determinants of health, for that population I would highly recommend what’s called the Bridge Model. And the Bridge Model, quite straightforwardly, is social work-led transitional care. Same exact concept. We start before the point of discharge to have that effective engagement, and we continue through the 30 days or so post-discharge. And the big contribution of the Bridge Model is they focus on – much like the Naylor Model with a very holistic geriatric needs approach, the Bridge social work model of transitional care focuses also on the whole person. And thinking about how do you get your food, where does your income source come from, where is your housing, is it stable or unstable? How is your mood and how are your coping skills and what is your social fabric for support, and linking people to not just appointments and ensuring they get medications, but in helping them build the fabric of a supportive environment so that they can do well moving forward on their own. I’m very happy to say just as the Naylor Model is measurably effective and evidence-based, the Bridge Model is also evidence-based and highly effective, and many people did not see the Journal of the American Geriatric Society article that I wrote doing an evaluation of the Bridge Model using all-cause, any hospital readmission measures, the broadest possible measure of effectiveness. And this was coming out of Rush University, a busy inner-city medical center in Chicago, and the Bridge Model was deployed for patients at highest risk of readmission, and the social worker delivered 30-day transitional care just as I described attending to whole-person needs in a very broad context, and the results of that analysis showed a 20% statistically significant reduction in all-cause readmissions for this very high-risk population. So it’s a great practice. I would say Naylor for the older adult. Nurse practitioners getting quite involved in medical care, decision-making, and attending to holistic geriatric needs in that transitional care period, or social workers delivering this Bridge Model of transitional care, and I would say that the most effective approach for a hospital would be to have both, because that’s what your data would suggest is necessary.
Kathy: Now the emergency department is where many patients have their first contact with a hospital. Where does the ED play a role when it comes to readmissions reduction efforts?
Amy: Oh, I’m so glad you asked that because I have run literally four collaboratives at the state and national level called The Role of the ED in Reducing Readmissions. So this is one of my favorite topics, and it is such a high leverage strategy to be ready to respond to the patient who is coming back within 30 days, we need to have some basic processes in place because, again, going back to our appreciation of the importance of the patient interview, we know that patients come back or are sent back to the emergency room for a variety of reasons, and many of them are not for emergencies. So a bump in the road, a call at the end of a clinic day to a nurse triage line, a home health nurse that can’t get a doctor on the phone, a dialysis center that’s noticing a low-grade fever, all of these are reasons why a patient would be sent to the emergency department that are not emergencies. However, when a patient has been recently hospitalized, old emergency medicine training, or I should call it classic emergency medicine training literally taught our emergency medicine physicians that if a patient was hospitalized and they’re back, that should ought to be thought of as a quote - failed discharge – and that they should go back to the team that treated them, because the team that treated them had a failed discharge plan. That is old thinking – much, much before the 2000s – but we need to appreciate that many of our emergency medicine physicians were literally taught that that was the decision to make. If they were hospitalized and they’re back, it’s called a failed discharge, the response to a failed discharge is to return them upstairs to the team that knew them most recently. Many nurses and even physicians do not know that that was emergency medicine theory for a long time. Now, luckily, emergency medicine is modernizing just as we all are, and that approach is melting away, and so we have a great opportunity in the emergency room to do a couple things. I call it the ABCs in this most recent collaborative that I am leading. So ABCs would be the ABC formula for any effort to reduce readmissions no matter what you’re going to do in the emergency room, meaning which staff you’re going to deploy, or what of a variety of strategies you may implement, all efforts to reduce readmissions from the emergency room have to have three elements in place. Number one is we need to engage the emergency room in our quote - upstairs efforts - to reduce readmissions. So it’s still common these days that readmission reduction committees are quote - upstairs committees - they involve quality, and hospital medicine, and case management, and social work, and maybe a transitional care team, and then the cross-continuum partners. But you’ll notice in that committee list, there’s no one from the emergency room. So job number one is include the emergency room in your hospital efforts to reduce readmissions. So we’ve got to engage them and include them on our readmission committee, if you will. Number two is we have to have some way of knowing that the person who just registered in triage is a 30-day return. They’re not yet a readmission, but they are coming back within that 30-day clock. The good news is that many - but not all - ED tracker boards have some sort of flag indicating this. The big thing that listeners would want to check on is to go down to your emergency room and look on the tracker board and ask yourself is there any way I would know, looking at these 20 names on the tracker board, which one of these 20 people are back within 30 days of discharge. I’ll tell you a quick story: one day, I walked down into – I’m a hospital medicine physician and I do a lot of admitting, and I admit my patients from the emergency room, and so one day I walked down into the emergency room and I looked at the tracker board and immediately it was so obvious, I’m sad to say, it was so obvious, I saw all of these green boomerangs on the tracker board, and because I do what I do I immediately intuitively knew what that must have meant and I just cringed because I’ll tell you what – there were a lot of boomerangs. And I went over to one of my emergency medicine colleagues and I said, “Hey, what are these little green curly thingies on the tracker board?” And she said, “Oh, I don’t know.” And I said, “I wonder what happens if you hover over it,” and we hovered over it and it said 30-day return. And she goes, “Oh, I guess that means they’re a bounceback.” And I said, “Well what are we supposed to do about this, if there’s one of these green boomerangs?” And she said, “I have no idea, I’m just going to do what I always do.” Right? So A) this is a cautionary tale, we need to have a visual marker on the tracker board, however, we would also be obligated to inform our staff what the marker means and what we want them to do about it. OK. And then the third thing we would need to have in place is ask why, so going back to the top of the podcast. We need to get in the habit of not just asking what is your chief complaint – chest pain, headache, whatever the case may be, but to look at that marker and say, “I see you were just here in the hospital, can you tell me what brings you back?” And to open up that root cause patient interview right then and there in the emergency room to allow us to discover that the patient might have been sent in or experienced a bump in the road or couldn’t get something that they needed that led them back to us, which is not truly an emergency. And so if we engage the ED, if we create a visual cue on the tracker board, to identify which patients are 30-day returns, and we ask that in our assessments, either at triage or the initial nursing or physician assessment, we purely add the question, “I see you were discharged recently from the hospital, can you tell me a little bit about what brings you back here today?” so that we can uncover those opportunities where there were just miscommunications, bumps in the roads, or frustrations, then we are set up to be able to safely and appropriately meet someone’s needs and discharge them from the emergency room and not incur a readmission.
Kathy: Again, that circles back to what you said before about having a more patient-centric view and understanding their experience. Now how about high utilizers? What steps can hospitals take to address them?
Amy: Oh, if I said before root causes were my favorite topic, then I will have to update it with multi-visit patients. I have been fortunate to lead the most – the launch and implementation of the most multi-visit patient delivery system transformation teams of anyone in the United States. And it has been quite an experience to learn specifically about multi-visit patients, and what – and to develop what I now call the MVP Method, which helps teams create a distinct and different care pathway specifically designed to be better prepared to meet the needs and issues we encounter in our MVP population. So briefly the idea here is a long, long time ago before door to balloon time people would have heart attacks in the field and we would bumble and stumble and try our hardest each and every one of us to get them from the point of having their critical heart attack to maybe or maybe not getting into the cath lab. And what we being healthcare needed to do was develop a cross-setting interdisciplinary care pathway to systematically respond to this unique and pressing crisis, which would be the STEMI heart attack and get them into the cath lab for life-saving or heart, myocardial-saving treatment. It’s the same principle that we’re applying here to MVP care. Which observes that numerous different disciplines across different departments and even agencies healthcare providers and non-healthcare providers are going to need to develop a standardized, shared process to improve care for multi-visit patients. Why? Because as a population we’ve learned that multi-visit patients have what I’ll just simply call the MVP Syndrome, which means we should not be surprised when healthcare providers call these patients quote – complex-. Indeed, I prefer to not call them complex but rather to organize my thinking in saying they have the MVP Syndrome, which allows me to expect to find and look for the behavioral, social, and medical needs that they always have. And so when we call them complex it almost belies to us that we’re surprised at how many issues they have. But when we call something a syndrome, we go looking for the elements of the syndrome and then we confirm our suspicion that yes indeed they have medical, behavioral, and social issues, and thus we organize our approach to addressing those issues accordingly in a systematic and less, quote - complicated - way. So the short answer here on multi-visit patients is we need - the best transitional care readmission reduction process in the world does not help. They need a distinct, different, dedicated care pathway which is founded on the concept that high-utilization is not a problem, which is what we all say it is, but rather, we frame-shift and just like everything else in clinical care we say high utilization of the acute care setting is actually a symptom. And just as when a patient presents to me with cough, it’s my job to figure out which of the 13 different reasons for cough does this patient have, and then deliver the appropriate treatment for cough caused by GERD, or cough caused by a blood clot. Very different treatments. And so when we think about high utilization, as a symptom of an unaddressed or inadequately addressed issue, then we develop a differential diagnosis approach, we figure out what is the driver of utilization, as we call it in the MVP method, and then we address the driver of utilization in a tailored way just as I would treat cough due to GERD in a very different way than I would treat cough due to a blood clot. And I think this is just the most exciting breakthrough in actually applying clinical decision-making to patients who are experiencing high utilization, and it makes so much sense to teams when we frame shift and look at this patient group through that lens that I’m happy to say that the MVP method has been implemented by over 200 teams nationally in just the past four years. And we’re deploying new teams literally every month across the country, so it’s a great new practice that perhaps will be food for another podcast in the future.
Kathy: That’s great. Now let’s talk about measuring success. How should hospitals think about measuring their success in readmissions?
Amy: Yeah, so the important thing here is a dashboard. So the dashboard should always have in your view hospital-wide all-cause adult non-OB readmissions. So, that was a mouthful, but for those of you who are familiar with readmissions you would know that for readmissions the lingua franca is we’re always looking at adults and we’re not looking at OB. And so it’s adult non-OB, all-cause readmissions. So we should be trending that for our own hospital on a month-to-month basis. That’s the frame of reference. So in addition to that we need the month-to-month tracking of your target population. And – or target populations, as I would recommend. So for example, let’s just pull from some of the data-based high-risk target populations, so every hospital would have a heart failure readmission reduction initiative, so you should be tracking month-to-month on the same graph, your all-cause heart failure readmission rate. The most important thing here where I see hospitals falter is in order to track an all-cause heart failure readmission rate or COPD or sepsis or whatever you quote - high risk -, you need to identify all the heart failure patients in your target population every day. And the number of discharges is your denominator. Many hospitals fail to identify and we’ll call it create a record or a registry of the patients who meet their high-risk criteria. And as such, if we fail to create a denominator then you can’t possibly track readmission rates for your target population. And the classic mistake that I’m seeing just all over the place, and I don’t know why this is such a – this is so pervasive, is we’re letting our EMRs identify who is high-risk for readmission. That’s a fireside chat for another day, but let’s just say you’re doing that, you’re using your Cerner, your Epic, or other EMR readmission risk predictor. Well, if you’re going to do that you need to then be able to say at the end of the month how many discharges did Epic tell us were high risk of readmission? Most teams who are using the EMR-based risk score are not tracking that. And thus, they can’t say to themselves or anyone else we had 100 discharges and of those 100 discharges, 20 came back for a 20% readmission rate. You absolutely have to do that for any given target population, whether it’s heart failure, or your Epic or Cerner, or EMR-based risk score that you’re acting on. So those are the two things – number one is hospital-wide, all-cause, adult non-OB readmissions, graphed month-to-month, and your target populations. If you’re asking any clinician to do anything different because somebody’s quote - high risk of readmission -, you have to know how many high-risk of readmission discharges did you have this month, and then you have to wait 30 days to say how many of those discharges returned within 30 days of discharge and that is your numerator and thus your readmission rate for that target population. Measuring in this way is tried and true with all of the teams I’ve worked with in terms of helping close the gaps and achieve better performance, so it’s very much worth it to get that basic infrastructure in place.
Kathy: Now if you could pick one thing that you think would be most impactful in reducing readmissions, what would that be?
Amy: It would be to walk away from disease-specific thinking. Readmissions are a function of people leaving the healthcare system, going out into the community, and people deciding that they need to come back. And so we need to embrace the holistic, whole person, social, logistical, and even frustration element of readmission. So when we look less at optimizing disease-specific management, and we look more at the whole person and the decisions they need to make and the support they need to have in order to stay out of the hospital instead of return to the hospital, teams do much better. So the major pivot in – pivot away from disease-specific care, narrowly conceived-of care pathways, and move toward delivering holistic, whole-person care, even for those same people with heart failure or COPD, they need whole-person care, not just good heart-failure care, and if you make that pivot, you’ll get better results.
Kathy: Now what progress do you expect in the next five years?
Amy: I am a student of policy; my two degrees are in medicine and public policy. And part of what has been so fascinating for me, working on readmissions all day every day for 12 years, has been the impact of public policy in this particular element of healthcare delivery. And so in the next five years I expect that public policy will continue to exert the market forces that it has, in fact we see very clearly that because of the public policy, public policy being Medicare and Medicaid, because of the public policy we see private sector payers expecting much, much more of their value-based contracts as well. So the public policy is pushing the market in ways that will get us in the next five years to maybe talk about readmissions less, and avoidable hospital use more, and what I want to leave listeners with is something that I’m seeing right now. Because this is happening right now, right, in our pursuit of value-based care, we’re talking about total cost of care, and Medicare and Medicaid and commercial ACOs are talking about total cost of care, and hospital utilization of course is one of the most expensive drivers of the cost of care. So we’re seeing some teams maybe prematurely take their eye off the ball of readmissions as that inner circle and move quickly, maybe even prematurely for their capacity, or capability, from readmissions to saying, oh well we don’t care about readmissions, we care about total hospital utilization. And yet readmissions is the inner circle of total hospital utilization. So my guidance and my anticipation for the next five years is that yes, we are moving certainly in accelerated fashion into value-based care which will have the ultimate outcome marker be total cost of care. Teams would be wise to master the approaches that we’ve discussed this hour on the podcast in terms of data, root causes, a multi-faceted portfolio of strategies that includes behavioral health and social needs, and focuses on supporting the whole person. And as you do that for readmissions you would then be able to apply that to multi-visit patients, bringing down hospital use, ED use, and readmissions, and then you would want to move out maybe to the broader circle of avoidable hospitalizations writ large. But remember that readmissions is the inner circle of total cost of care driven by hospital utilization and so don’t just wipe that off of your screen because now we’re focused on total cost. I think that would be possibly a logical but misguided step in the next five years.
Kathy: Well, Amy, thank you so much this was a great conversation. I learned a lot; I think our listeners probably learned a lot as well. So thank you.
Amy: Thank you so much, it’s been a real pleasure.
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Kathy: Thank you all for listening to this episode of the Smarter Healthcare Podcast. If you like what you hear, please subscribe on your favorite podcast app, and don’t forget to rate and review us!
You can also find us online at www.smarthcpodcast.com. We have a “resources” tab there, and one of the resources you can find is Dr. Boutwell’s guide on readmissions called, “Designing and Delivering Whole-Person Transitional Care.”
In addition, you can find us on Twitter @smarthcpodcast. Feel free to tweet me @ksucich if you have any comments or guest suggestions.
Thanks for joining us today!
